APA format, The Topic is COPD, I attached the grading rubric and the soap note for COPD. writer can modify the SOAP note Assignment 1: Grand Rounds AssignmentThis week begins Grand Rounds presentations. In Week 1, the instructor assigned each student a week in which to present (Week 3, 5, 7, or 9). Those who are not presenting this week are responsible for participating in at least two presentations. Once again, keep in mind the following guidelines while taking part in this assignment:For those who are presenting this week:Your presentation must include:Three learning objectives that must be clearly written and presentedA complete SOAP on the approved templateAn extended SOAP noteAt least five test questions (such as multiple choice and/or matching) designed to asses mastery of the learning objectivesA minimum of five scholarly resourcesPost your presentation to this Discussion Area by Saturday, April 29, 2017. Begin facilitating the discussion and continue to lead it throughout the week.For those who are participants this week, begin participating on Saturday, April 29, 2017, and continue until the end of the week.Additional GuidelinesFor the presenters:Your goal is to present your case as a teaching presentation and lead a discussion throughout the week.Here are some tips for facilitating the discussion:To prepare for your presentation, rehearse the key points and findings of your research and think about points you can make to initiate the discussion and keep it going.Develop questions you can ask to initiate the discussion and keep it going.As you approach the end of the discussion period, ask participants to: Summarize the discussion.Draw conclusions from the collective group discussion.Keep the presentation interesting, professional, and focused on the topic. APA format is expected, and references should be cited.For the participants:Those not assigned to present this week should participate in all Grand Round Discussions. Here are some guidelines for participation:Prepare for the discussion by reading the presenters’ submission.Keep your participation at the level of critical thinking—analyzing, synthesizing, and evaluating. Make connections between what you are learning in this course and what you already know.Make comparisons and challenge points of view. Interact with both presenters and other students.Add to the experience using what you might have read about the topic or experienced personally.Be prepared to substantiate your points of view.At the end of the week, be prepared to summarize or draw conclusions from the presentation experience.
assignment_1_grading_criteria.docx
copd_soap_note.docx
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Assignment 1 Grading Criteria
Maximum
Points
When You Are a Presenter:
Identified a minimum of three learning objectives and
five test questions. Learning objectives are written in a
clear and concise manner.
5
Identified a diagnosis that has been covered in course
materials up to this week and created a completed
extended SOAP note and evaluation following template.
Presented pathophysiology of the disease process
contributing to this patient’s diagnoses.
15
Proposed and discussed a treatment plan, education plan,
and follow-up plan based on clinical guidelines and
current literature. Identified and described research
material to support the diagnosis and plan. Described best
practices for optimal outcomes.
10
Provided a critical reflection of interaction and
investigation. Evaluated the patient encounter and
finished with concluding remarks that highlighted the
learning objectives.
5
Included a minimum of five scholarly resources with
maximum of one course text—no secondary sources.
Included clinical guidelines and literature that provided
the evidence for the diagnosis, therapeutic plan and
education. References followed APA guidelines.
5
Facilitated a discussion relevant to the presentation topic.
10
Total:
50
Chief Complaint
SOB, edema
Last known as asymptomatic
Patient last asymptomatic (Date/Time) Apr-21-2017 @ 1200
HPI / Subjective
Mr Lopez is an 89 yo M with a PMHx of HTN, COPD, PVD, CHF and nicotine dependence. He presented to
the LCH ED for worsening SOB. He stated that this is a chronic issue that has come and gone over the
last year; and that in the last few days it has progressively worsened. he says that he is getting
significantly SOB with exertions and at rest. He says that it gets minimally better with rest. He also has
had B/L LE edema for the last week or so, stating that it is painful to move around. he is complaining of
body pain all over and that it is uncomfortable to move around a lot. Patient has had red eye with
discharge for the last 5 days. Reports no vision changes. Patient is A&Ox3 , calm and cooperative to
exam and interview.
Home Medications
HYDROCHLOROTHIAZIDE (HCTZ)
Dose: 12.5 MG BY MOUTH DAILY
MOTRIN
Dose: 600 MG BY MOUTH DAILY
PRINIVIL
Dose: 5 MG BY MOUTH DAILY
VENTOLIN HFA 108 (90 Base) MCG/ACT
Dose: 1 PUF INHALATION EVERY 8 HOURS
Past Medical History
HTN, PVD, COPD, CHF
Past Surgical History
hernia repair as reported by the patient
Allergies
No Known Allergies
Social History
tobacco use
Current Every Day Smoker
marital status
Unknown
Review of Systems
Constitutional
Fatigue, Weakness
Negative For: Fever, Malaise, Myalgia, Night sweats, Loss of appetite, Weight loss, Irritability
Skin/Lymphatic
Edema
Negative For: Rash, Lesion, Itching, Bruising
HEENT
Head
Negative For: Headache, Dizziness, Vertigo
Eyes
Red , Discharge
Negative For: Blurred vision , Visual Loss
left eye, upper lid
Ears
Negative For: Pain, Discharge , Tinnitus
Nose and Sinuses
Negative For: Nasal discharge, Nasal congestion, Sinus pain, Nose bleed
Mouth and Throat
Negative For: Sore throat, Hoarseness, Toothache, Jaw pain
Neck
Negative For: Enlarged lymph nodes, Pain, Stiff neck, Swelling
Respiratory
Cough, SOB – Shortness of breath, Fast Breathing, Wheezing, Orthopnea
Negative For: Producing sputum
Cardiac/Peripheral Vascular
Swelling, Abnormal blood pressure, Pain in calf
Negative For: Cyanosis, Chest pain, Palpitations
GI
Negative For: Nausea, Vomiting, Diarrhea, Constipation, Bright red blood in stool
GU
Negative For: Dysuria, Frequency, Flank pain, Urgency
Neurological
Weakness
Negative For: Headache, Numbness, Loss of consciousness, Tremor
Musculoskeletal
Muscle weakness
Negative For, Fracture, Joint stiffness, Joint swelling, Low back pain, Muscle pain, Trauma
Psychiatric
Negative For: Anxious, Agitated, Depression, Insomnia, Hallucinations, Hearing voices, Homicidal
thoughts, Suicidal thoughts
Physical Exam
Vital Signs
Pulse 62 BP 187/90 RR 22 PO2 94%
PE – General
Appearance consistent with age(Appearance consistent with age), Awake, Alert, Oriented to place
(finding), Oriented to person
Negative For: Respiratory Distress, Disorientation, Lethargic, Delirium, Distress, Somnolence
PE – Skin/Integumentary
Skin Moisture
Dry skin
Positive For: Edema.
Negative For: Diaphoresis, Dehydrated
Hair
Positive For: Male patter baldness.
Nails
Yellow nails
PE – HEENT
PE – Head
Positive For: Head normal shape (Head normal shape).
Negative For: Facial swelling, Facial grimacing, Ptosis of eyelid, Paralysis, Traumatic AND/OR nontraumatic injury
PE – Eyes
Left Conjunctival Color (red medially)
Bilateral Pupils equal, Pupils accommodating
Positive For: Eye movements normal. Left Conjunctival discharge (left eye). Bilateral Pupil round, Pupil
reactive to light.
PE – Ears
Positive For: Bilateral Patent.
Negative For: Foreign body, Edema, Debris, Tenderness, External drainage
PE – Nose
Patent
Positive For: Symmetry.
Negative For: Nasal deviation, Epistaxis, External drainage, Swelling, Inflammation
PE – Sinus
Negative For: Tenderness
PE – Mouth and Throat
Positive For: Dental caries.
Negative For: Gingivitis, Multiple plaques, Halitosis, Red throat, Exudate, Dysphagia
PE – Neck
Supple
Positive For: Symmetry.
Negative For: Tenderness, Endotracheal tube, Lymphadenopathy, Swelling, Mass
PE – Respiratory
Decreased breath sounds
Positive For: Expiratory wheezing, Shallow breathing, SOB – Shortness of breath, Wheezing.
Negative For: Normal breath sounds – clear and equal, Stridor, Tachypnea, Rales, Rhonchi
PE – Cardiovascular
Heart sounds (S1 S2)
Positive For: Bradycardia.
Negative For: Heart murmur, Gallop, Thrill
PE – Abdomen
Soft (Soft), Flat
Negative For: Hypoactive bowel sounds, Hyperactive bowel sounds, Hernia, Murphy sign, Distention,
Abdominal Guarding, Abdominal Rebound Tenderness, Tenderness, Enlargement/Organmegaly
PE – Musculoskeletal
Negative For: Misalignment, Mass, Subluxation of joint
PE – Peripheral Vascular
Positive For: Edema of lower extremity.
Negative For: Cold extremities, Edema of the upper extremity, Clubbing of nail, Peripheral cyanosis,
Atrophic condition of skin
PE – Neurological
Normal neurological function
PE – Psychiatric
Positive For: Stable.
Negative For: Paranoid, Mood swings, Inappropriate behavior, Inappropriate affect, Depressive disorder,
Agitated, Anxiety, Angry
Lab Results
Apr-25-2017 1121
SAMPTYPE Blda, O2DEV Room Air, SITE L Radial, ALLENS Pos, PH(T) 7.37, PCO2(T) 59, PO2(T) 67, BE(B)
6.3, HCO3ACT 33, AA 0.85, AADO2 12, THB 13.3, SO2 92.3, O2HB 90.5, COHB 1.7, METHB 0.2, HHB 7.6,
TEMP 98.6, FIO2 21.0
Apr-25-2017 1100
GLU 114.2, BUN 20.2, CREA 0.87, NA 142.9, K 3.95, CL 105.1, CO2 32.6, CA 8.74, TP 6.36, ALBUMIN 3.47,
BILIT 0.67, AST 28.2, ALT 22.0, ALKP 56.7, BUN/CREA 23, OSMO 288.4, GLOB 2.9, A/G 1.2, GFR 88, WBC
4.1, RBC 4.27, HGB 13.0, HCT 40.3, MCV 94.4, MCH 30.4, MCHC 32.3, RDW 14.6, RDWSD 49.0,
PLTCOUNT 165.0, MPV 11.0, %NEUT 62.9, %LYMPH 26.7, %MONO 8.7, %EOS 1.5, %BASO 0.2, #NEUT
2.6, #LYMPH 1.1, #MONO 0.4, #EOS 0.1, #BASO 0.0, BNP 287
Other Results
CXR- Lung hyperinflation with flattening of the diaphragms consistent with COPD. Tenting of the left
hemidiaphragm which may relate to atelectasis or parenchymal scarring. Prominent interstitial opacities
in the bilateral lung apices which may be chronic in nature. No discrete focal consolidations or pleural
effusions.
Assessments
Congestive heart failure
Chronic obstructive lung disease
Edema
Plan
CHF-EKG bradycardia
– Cardio Dr. Dylewski consulted, appreciate recommendations
– BNP at admission 4/25/17 287
– ECHO ordered
-Cardiac enzyme and coags ordered
–
COPD- ABG: pH 7.37 PCO2 59 PO2 67 HCO3 33 SiO2 92.3, repeat in the AM
– on 2 L NC
– monitor pulse ox continuously
– duoneb Q6h, solu-medrol 100mg Q6hr
– Pulm consulted Dr. Yatzkan, appreciate recommendations
Edema- B/L LE US venous ordered
– likely secondary to CHF exacerbation, need to rule out DVT due to pain
– monitor for worsening
Patient is admitted to the ICU for close observation.
HOB to 45 degrees, aspiration precautions, fall precautions, bedrest- patient can use bedside urinal
Home medications continued. No IVF at this time due to the CHF exacerbation. Will monitor kidney
function, if worsening will start low IVF.
Consultations
Cardio- Dr Dylewski
Pulm- Dr. Yatzkan
…
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